Are all children with visual impairment known to the eye clinic?

Assistive technology needs, access and coverage, and related barriers and facilitators in the WHO European region: a scoping review

PURPOSE

Globally, assistive technology (AT) is used by over 1 billion people, but the prevalence of needs and access to AT in specific countries or regions is largely unknown. This scoping review summarises the evidence available on the prevalence of needs, access and coverage of AT in the World Health Organisation European Region and the barriers and facilitators to its use.

METHODS

Relevant publications were identified using a combination of two strategies: 1) a systematic search for AT publications in five scientific literature databases; and 2) consultations with 76 of the Region's AT experts.

RESULT

The search strategies yielded 103 publications, 62 of them identified by the systematic search. The included publications were predominantly from six countries, and 18 countries were unrepresented. Information on AT use for specific functional impairments was present in 57 publications: AT for hearing impairment in 14 publications; vision in 12; mobility, 12; communication, 11; self-care, 6; and cognition, 2. AT needs for vision and hearing impairment were more likely to be met (1-87% and 5-90%, respectively) compared with communication and cognition impairments (10-60% and 58%, respectively). The barriers and facilitators to AT access described were linked to accessibility, affordability and acceptability.

CONCLUSION

Data on AT prevalence and coverage are limited in both quantity and quality. Agreed-upon definitions of functional impairment and assistive product categories and standards for data collection are needed to facilitate data comparisons and to build a more representative picture of AT needs and coverage.Implications for rehabilitationComprehensive and disaggregated data concerning the prevalence of needs and coverage of AT is needed to enable the development of responsive policies and actions.The literature available on the prevalence of needs and coverage of AT in the WHO European Region is primarily focussed on a small subset of countries and comparisons between studies are limited due to the use of different data collection strategies.Evidence concerning barriers and facilitators to AT access across countries is more consistent and can be organised across the key themes of accessibility, affordability and acceptability of AT.There is a need for consensus among multiple AT actors on standardised definitions for functional impairment and assistive product categories and standards for data collection to enable a more representative picture to be built of AT needs and coverage across the WHO European Region and globally.

Clinical assessment, investigation, diagnosis and initial management of cerebral visual impairment: a consensus practice guide

Cerebral Visual Impairment (CVI) is a common condition in the UK. Patients with conditions associated with CVI are frequently seen in paediatric ophthalmology clinics offering eye care professionals an opportunity to identify children proactively. In most cases CVI occurs as part of a neurodevelopmental condition or as a feature of multiple and complex disabilities. However, CVI can also be seen in children with apparently typical development. In some cases, high contrast visual acuity is normal and in other cases severely impaired. As such, identification of CVI requires evaluation of aspects of visual performance beyond high contrast acuity and consideration that visual function of those with CVI may fluctuate. Few paediatric ophthalmologists have received formal training in CVI. The detection and diagnosis of CVI varies across the UK and patients report hugely different experiences. A diagnosis of CVI is made based on professional clinical judgement and it is recognised that individual perspectives and local practice in the specific methodologies of assessment will vary. A systematic review and survey of professionals is underway to attempt to reach agreement on diagnostic criteria. Nonetheless, established pathways and published protocols can offer guidance on how a paediatric ophthalmology service can approach assessment of the child with suspected CVI. The purpose of this paper is to present a summary of research and clinical practice methods for detecting and diagnosing CVI in a paediatric ophthalmology outpatient setting. It represents current understanding of the topic and acknowledges the evolving nature of both practice and the evidence-base. A rapid literature review was undertaken to identify articles relating to clinical investigation of children with CVI. A focus group of QTVI and subject matter experts from sight loss charities was undertaken to address areas which were not covered by the literature review.

Visual Behaviours (ViBes) in Cerebral Visual Impairment: Validating a Descriptive Tool to Support Diagnosis and Monitoring

Introduction

Cerebral visual impairment (CVI) is the most common cause of visual impairment in children in the UK. Diagnosis is based on identification of visual behaviours (ViBes) relating to visual dysfunction. Examination techniques and inventories have been developed to elicit these in children with a developmental age of two years or more. The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis. The aim of the study was to develop a matrix of visual behaviours seen in pre-verbal and pre-motor children with visual impairment and establish its content validity and inter-rater reliability.

Methods

ViBe content validation:: Visual behaviour descriptors relating to visual function were collated and categorised by expert consensus of vision professionals into a matrix composed of three functions (attention, field/fixation, motor response) and five levels (0 = no awareness; 1 = visual awareness; 2 = visual attention; 3 = visual detection; 4 = visual understanding).ViBe inter-rater reliability:: The participants (two orthoptists, an optometrist, an ophthalmologist and two qualified teachers of the visually impaired) used the ViBe matrix to independently score each of 17 short video clips of children demonstrating visual behaviours seen in CVI.

Results

The ViBe matrix will be presented. Cohen's kappa for the matrix was 0.67, demonstrating moderate-to-strong inter-rater reliability.

Conclusion

The development of standardised descriptors can support clinicians and teachers in identifying areas of concern for children with complex needs. In addition, the ViBe matrix could be utilised in research, clinical and diagnostic reports to clearly communicate the areas of visual dysfunction and track progress resulting from interventions.

Key Points

The absence of a structured approach to recording visual behaviours in children with complex needs is a barrier to diagnosis.The ViBe matrix offers descriptors relating to visual behaviours and has demonstrated acceptable inter-rater reliability.The tool may support the identification and diagnosis of cerebral visual impairment in a population of children who cannot access standard testing.

Referral thresholds for an integrated learning disability eye care pathway: a consensus approach

INTRODUCTION

Local Optometric Support Unit (LOCSU) have published their refreshed clinical pathway for eye care for people with a learning disability. The document sets out the adjustments to practice that a community optometrist might make in order to provide optimal care for a person with learning disability attending a primary eye care assessment. The pathway specifically points to the need to retain patients in primary care where appropriate and 'reduce the number of people with learning disability who are inappropriately referred into the Hospital Eye Service (HES).' Pivotal to this refreshed pathway is the integration with secondary care, with local arrangements to facilitate referral and hospital management where appropriate. There are few ophthalmologists nationally who frequently encounter patients with a learning disability in their hospital practice and knowing where to start when creating referral criteria or KPIs may create a barrier to services becoming established. In order to address this gap in experience, we set about developing a set of consensus statements regarding referral thresholds for ocular conditions commonly encountered in adults with learning disability.

METHOD

A series of video interviews were undertaken with eye health professionals with a range of experience in eye care for people with learning disability. Each contributor commented on the usability and clarity of each element of the referral criteria. In addition, each contributor was asked to express the overriding principles by which they make decisions regarding referral thresholds for patients with learning disability. These were collated into the final document which was circulated and agreed by all participants.

RESULTS

A table setting out referral thresholds for commonly encountered eye conditions in adults with learning disabilities is presented.

CONCLUSION

We have presented a succinct set of consensus statements relating referral thresholds for common presentations of visual problems in adults with learning disability in the UK distilled from the collective experience of a group of eye health professionals. The intention was not to present a comprehensive review of management of each condition. Rather, the consensus statements may form the starting point from which each area could develop locally agreed criteria, as is suggested by the LOCSU pathway guidance.

Pinhole does not increase screening accuracy of detecting decreased best corrected visual acuity in schoolchildren

Background

Decreased best corrected visual acuity among children should be treated early in life, and vision screening in schoolchildren is an efficient and feasible selection for developing countries. Thus, the screening accuracy of different visual acuity tests is the key point for making vision screening strategies. The present study aims to explore the screening accuracy of uncorrected visual acuity (UCVA) and pin-hole corrected visual acuity (PCVA) using different vision chart in the detection of decreased best-corrected visual acuity (BCVA) among schoolchildren.

Methods

Grade one primary schoolchildren in urban Lhasa with data of UCVA using tumbling E chart (UCVAE), PCVA using tumbling E chart (PCVAE), UCVA using Lea Symbols chart (UCVAL), PCVA using Lea Symbols chart (PCVAL) and BCVA using Lea Symbols chart were reviewed. Decreased BCVA was defined as BCVA≤20/32(≥0.2 logMAR). Difference, reliability, and diagnostic parameters in the detection of decreased BCVA of different visual acuity results were analyzed.

Results

Overall, 1672 children aged 6.58 ± 0.44 years fulfilling the criteria. The prevalence of decreased BCVA was 6.8%. Although no significant differences were found between UCVAE vs UCVAL (p = .84, paired t-test) as well as PCVAE vs PCVAL (p = .24), the ICC between them was low (0.68 and 0.57, respectively). The average difference between BCVA and UCVAE, UCVAL, PCVAE, PCVAL was logMAR -0.08 (− 0.37, 0.21), − 0.08 (− 0.29, 0.17), − 0.05 (− 0.30, 0.19), − 0.06 (− 0.23, 0.12) using Bland–Altman method. The area under the receiver operating characteristic curve of UCVAE, PCVAE, UCVAL, PCVAL for the detection of decreased BCVA was 0.78 (0.73, 0.84), 0.76 (0.71, 0.82), 0.95 (0.94, 0.96), 0.93 (0.91, 0.95), respectively.

Conclusion

Pinhole does not increase the screening accuracy of detecting decreased BCVA in grade one primary schoolchildren. Visual acuity test using Lea Symbols is more efficient than Tumbling E in the screening of that age.

Trial registration

Data were maily from the Lhasa Childhood Eye Study which has finished the clinical registration on (ChiCTR1900026693).

How accessible is primary eye care for children in England?

PURPOSE

Good vision during childhood is vital for visual, educational, and social development. Previous research highlights challenges in the accessibility of eye care for children. This study investigates the accessibility of primary eye care for young children with typical development and those with autism in England.

METHODS

A telephone survey was conducted using four hypothetical scenarios (a child aged 1, 3, 5 years and a 13-year-old with autism). Four hundred community optometric practices (100 different practices for each scenario) were contacted to explore the availability of an eye examination. The caller acted as a parent, asking about the availability of an eye examination for their child and raising concerns regarding the child. Key barriers and enablers to the accessibility of primary eye care were identified through an analysis of qualitative information.

RESULTS

Of the 400 practices, only three (<1%) stated that they do not perform eye examinations on children. Fifty-six practices (14%) stated that they would examine a child at any age, the remainder (n = 341, 85%) specifying a minimum age at which they would perform eye examinations on children. Lack of 'communication' from the child and 'equipment' were identified as barriers to accessing eye care for young children. Eye care for children with autism was enabled by factors related to adaptability and appointment time.

CONCLUSION

Our results suggest that communication and a lack of appropriate equipment for examining children are potential barriers to accessing primary eye care. No clear barriers were identified for an older child with autism. Eye examinations are more accessible for older children in these scenarios (aged 5 with typical development and 13 years with autism) than younger children (aged 1 and 3 years old). While the UK General Ophthalmic Services (GOS) terms do not permit contract holders to exclude categories of patients from a GOS eye exam, our findings suggest this is taking place.

Parents and teachers of children in special education settings value in-school eyecare and written reports of visual status

Objectives

To evaluate parent and teacher opinion of the provision of in-school eyecare and jargon-free written reporting of visual status for children in special educational settings.

Participants and methods

A nationally-agreed, in-school eyecare framework for children attending special schools which recommends a full eye examination, dispensing of spectacles and provision of a jargon-free written report of visual outcomes to parents and teachers, was provided to 200 children (mean age 10 years, 9 months; 70% male) attending a special school in the UK. The written ‘Vision Report’ detailed, in lay-language, results from the eye examination and provided practical advice to alleviate the impact of vision difficulties both at home and in the classroom. Following implementation of the framework, parents and teachers completed a feedback questionnaire to determine their opinion of the in-school eye examination and utility of the Vision Report.

Results

Parents of 123 participants returned a feedback questionnaire. Eighty-eight participants were represented by the 23 teachers who returned a questionnaire. The in-school eyecare was rated positively for children in special education by 82.4% of parents and 80.9% of teachers. Key benefits included the familiarity of the in-school setting (81.3% of parents and 100% of teachers agree), the convenience of the setting for parents (74.0% of parents and 100% of teachers agree), and the opportunity for teachers to speak directly to eyecare providers regarding a child’s visual needs (82.6% of teachers agree). The information provided by the Vision Report was deemed useful day-to-day by 78.3% of parents and 100% of teachers. The majority (80%) of teachers implemented classroom modifications suggested in the report, whereas only 47.9% of parents reported implementation of modifications at home.

Conclusions

Provision of in-school eyecare is valued by parents and teachers of children in special education settings. Jargon-free, written reports of visual status are valued and utilised by parents and teachers. Further support is required to aid parents in implementing vision modifications at home.

In-school eyecare in special education settings has measurable benefits for children's vision and behaviour

OBJECTIVES

To determine whether implementation of comprehensive in-school eyecare results in measurable benefits for children and young people in terms of visual status, classroom behaviours and how well their visual needs are met.

DESIGN

School-based observational study.

PARTICIPANTS & METHODS

200 pupils [mean age 10 years 9 months, 70% male, majority moderate (40%) or severe (35%) learning difficulty] of a special education school in the UK. A sector-agreed in-school eyecare framework including full eye examination and cycloplegic refraction, dispensing of spectacles (as appropriate) and written reporting of outcomes to parents/teachers was applied. Classroom behaviours were observed and recorded prior to, and after, the in-school eyecare. Surveys were employed to obtain visual histories from parents/teachers. School records and statutory documents were reviewed for diagnostic and learning disability classifications. Visual function and ocular health were profiled at baseline and significant visual deficits identified. Where such deficits were previously unrecognised, untreated or not compensated for (e.g. correction of refractive error, enlargement of educational material) they were recorded as 'unmet visual need'. At follow-up, 2-5 months after initial (baseline) measures, eye examinations, parent/teacher surveys and behaviour observations were repeated. Follow-up measures were used to determine if measurable improvements were evident in visual function, ocular health, the level of unmet need and classroom behaviour following implementation of in-school eyecare.

RESULTS

199 participants completed baseline and follow-up measures. 122 (61%) participants presented with at least one significant visual or ocular health deficit and 90 (45%) participants had at least one unmet visual need. Younger pupils and those with no previous history of eyecare were more likely to demonstrate unmet visual needs at baseline (OR 1.12 95% CI 1.03 to 1.21) p = 0.012; (OR 4.44 95% CI 1.38 to 14.29 p = 0.007 respectively). On follow-up, the number of pupils with unmet visual needs dropped significantly to 36 (18%) (McNemar's test p<0.001). Visual and behavioural metrics of participants without significant visual deficits or whose visual needs were adequately addressed at baseline remained relatively unchanged between baseline and follow-up (Wilcoxon signed rank p>0.05). Where significant refractive deficits were corrected at follow-up, near visual acuity improved significantly (Wilcoxon signed rank p = 0.013), however, poor spectacle compliance was a persistent cause of unmet visual need. Off-task behaviour reduced significantly after actions to address unmet visual needs were communicated to parents and teachers (Wilcoxon signed rank p = 0.035).

CONCLUSIONS

The present study demonstrates for the first time measurable visual and behaviour benefits to children in special education settings when they receive comprehensive in-school eye examinations, on-site spectacle dispensing and jargon-free reporting of outcomes to teachers and parents.

Findings from an opt-in eye examination service in English special schools. Is vision screening effective for this population?

Our objective was to present the findings of an opt-in, school-based eye care service for children attending 11 special schools in England and use these findings to determine whether a vision screening programme would be appropriate for this population. Data from eye examinations provided to 949 pupils (mean age 10.7 years) was analysed to determine the prevalence and aetiology of visual deficiencies and reported eye care history. For 46.2% (n = 438) of pupils, a visual deficiency was recorded. 12.5% of all the children seen (n = 119) had a visual deficiency that was previously undiagnosed. Referral for a medical opinion was made for 3.1% (n = 29) of pupils seen by the service. Spectacle correction was needed for 31.5% (n = 299) of pupils; for 12.9% (122) these were prescribed for the first time. 3.7% (n = 11) of parents/carers of pupils needing spectacles chose not to use the spectacle dispensing service offered in school. Eye care history was available for 847 pupils (89.3%). Of the pupils for whom an eye care history was available, 44% (n = 373) reported no history of any previous eye care and10.7% (n = 91) reported a history of attending a community optical practice/opticians. Only one pupil from the school entry 4–5 age group (0.6% of age group n = 156) would have passed vision screening using current Public Health England screening guidelines. Children with a diagnosis of autism were significantly less likely to be able to provide a reliable measurement of visual acuity. This study supports previously published evidence of a very high prevalence of visual problems in children with the most complex needs and a significant unmet need in this group. It demonstrates routine school entry vision screening using current Public Health England guidelines is not appropriate for this group of children and very low uptake of community primary eye care services.

Is there evidence that the yearly numbers of children newly certified with sight impairment in England and Wales has increased between 1999/2000 and 2014/2015? A cross-sectional study

OBJECTIVES

To use routine data capture from hospitals in England and Wales to identify whether there has been an increase in the annual numbers of children newly certified sight impaired in England and Wales between 1999/2000 and 2014/2015 and to examine causes of certifiable sight impairment in children certified in 2014/2015.

DESIGN

A cross-sectional study including an analysis of all certificates of vision impairment completed in hospitals in England and Wales each year between 2007/2008 and 2014/2015 and all certificates completed in hospitals in England and Wales in 1999/2000.

PARTICIPANTS

Certificates for all individuals aged 16 years or less at the time of certification in England and Wales for each financial year between 1 April 2007 and the 31 March 2015 and for individuals aged 15 years or less for the year ending 31 March 2000. We obtained information on the main cause of certifiable sight loss for all children certified in 2014/2015. We estimated crude and sex specific incidence estimates with 95% confidence intervals computed by Byars method.

RESULTS

In 1999/2000, the estimated incidence (95 % CI) of certification was 8.2 (7.7 to 8.8) per 1 00 000. In 2007/2008, the estimated incidence was statistically significantly higher at 10.1 (9.5 to 10.7). Since then a trend of increasing incidence with time has been observed until 2014/2015 when an estimated incidence of 13.3 (12.6 to 14.0) was observed. Hereditary retinal dystrophies, cerebral visual impairment and nystagmus were the most common single causes of certifiable sight impairment in children in 2014/2015.

CONCLUSION

Our findings show that in England and Wales there has been an increase in the number of children newly certified sight impaired by consultant ophthalmologists since 1999/2000. This mirrors our previous findings based on data originating within social service departments.